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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7'000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
/714188 11
Date 'A Signature of Contractor,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner of the property, or my employees with wages as their Sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professiona Is
Code).
( ) I am exempt under Section —, B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code,* for. the
performance of the work for which this permit is issued. - .
K ) I have and will maintain workers' compensation insurance, as required by
section 3700 of the Labor Code, for the performance of the work for,which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
WNITH. 1.14& CO.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subj66t to the workers' compensation provisions of Section 3700 of the Labor
V?ode, I shall,forthwith comply with,those provisions.
Date: Z- V- Applicant 4-1*
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth orf , his
application.
1. Each person upon whose behalf this application is made & eac ' h person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance, of such
permit, or cessation of work for 180 days will subject permit to cance,llation.
I certify that I have read this application and state that the above information is
correcV1 agree to comply with all City, and State laws relating to the building
con
,,Atruction, and hereby authorize representatives of this City to enter upon
t 6above-mentione6 property.0 inspection purposes. -
III Signature (Owner/Agent) Date
DATE
JOB SITE
ADDRESS
OWNER
BUILDING PERMIT
I i 9197 VALUATION M610,971 .20 LOT
'79-115 CAMINO HOSADA
61-1*RNAkPFNQ i -'A
USE OF PERMIT
IS11,14)
RANCtio �X.X)11U,0 - HLAW 40.blk
PERMIT# CONTROL#
1041124-30 4589
77 TRACT 12,4517
APN 604-191-019
CONTRACTOR / DESIGNER / ENGINEER
M�
CR MITI JXA IMUNrl"It"s
153 i Sir). pf)" Rill I,' 11-11"FE, 4210
W11408 SAN BERINARDINO (-'A 92408
0W),�WI-6007 OR.# 21,10
TRAK2'r comwpwcnoN Z71.1s.00 Sli.,
PURUVVKQ0 96.00 3F
0JN_R.AC#'M'.M4 PCWT Sr
'41P ARAI, ICON !�1,Xf'D'cn_'QN AN01"P\N CIMCK
LESS PKE-RAID DEES
:_-.1 &
$5,214.81
. $517-14.81
FINALED INSPECTOR
iFIECEIPT DATE BY
PERM0,01"P NUUNIMARV
(1100,VP.U(Tf iGN VP:9
101-M)-418 4)00
PLAV CIFVFMIF'Er�
104-000-4319-W
$1,17 0
ry aA3 I AN f C t %- I " MS
101-000-41211-000
$85.50
PL.Lr-NOUNG F04S
101-OW419�000
1014M -2414W,
SKY)
101_0M
WF IR AS f UOTUYffi
2225�000-443-M
&�,593.12
AWr
701 -000�255-W
$02.43
'41P ARAI, ICON !�1,Xf'D'cn_'QN AN01"P\N CIMCK
LESS PKE-RAID DEES
:_-.1 &
$5,214.81
. $517-14.81
FINALED INSPECTOR
iFIECEIPT DATE BY
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATETINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
lZ44Za4
Return Air
Steel
///7/,., f
Combustion Air
Roof Deck
_-7
ExhaustFans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
31341ZZ
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final I '
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVA S
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
era[
. ............
Pool Cover
-�SEWer Connection
Encapsulation
Gas Piping
Gas Test
5ZATZf 7
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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